Evidence-based educational guidelines for stroke survivors after discharge home

Health knowledge after stroke in Switzerland: a survey among health professionals on current practice and suggestions for the implementation of a technology-based educational program for stroke survivors

BACKGROUND

It is estimated that 1 in 4 stroke survivors will experience a second stroke. Educating patients about risk factors for stroke and a generally healthier lifestyle may help prevent recurrent strokes, which are a burden on society and the healthcare system. The goals of this paper were to investigate the estimated level of knowledge of stroke patients regarding their disease, the methods of information commonly used in clinical practice, the topics that should be included in an educational program aimed at improving health knowledge among stroke survivors, and how such a program could be delivered with the help of technology-based education (i.e., information delivered by digital platforms such as smartphones or rehabilitation technologies).

METHODS

We performed a survey among health professionals working with stroke patients in Switzerland.

RESULTS

161 health professionals of different backgrounds took part in the survey, and 94 completed it. According to the results, only 33% of healthcare professionals thought that patients were well informed about stroke one month after stroke onset. These findings suggest that there is room for improvement in how stroke patients are educated about stroke, risk factors, and prevention. Additionally, it was highlighted that technology is not commonly used in clinical practice to support patients' education, although this is an acceptable method for healthcare professionals. The results also helped to identify key topics to be included in an educational program and recommendations for implementing such a program in rehabilitation technologies.

CONCLUSIONS

This work allowed gaining more insight into healthcare professionals' opinions on the potential of technology-based education and key aspects to consider when implementing it to support health and prevention knowledge after stroke.

Feasibility and user-experience of a virtual environment for social connection and education after stroke: A pilot study

OBJECTIVES

To evaluate the feasibility and usability of stroke survivor participation in an 8-week virtual environment intervention that provides opportunities for social support exchanges, social network interactions, and recovery education.

MATERIALS AND METHODS

A single-group, pre- and post-test measure design was used. Descriptive statistics were used to examine enrollment and retention rates, proportion of questionnaires completed, and virtual environment process data (e.g., number of log-ins) and usability scores. Changes in pre- and post-intervention questionnaire (e.g., usability, social support, depression, anxiety, loneliness, and self-efficacy) scores were explored using Wilcoxon signed-rank tests and paired t-test.

RESULTS

Fifteen (65 %) of the eligible stroke survivors enrolled (60 % white, 27 % black), 12 (80 %) had an ischemic stroke, ages ranged from 33 to 74 years (mean 44 years), and mean months since stroke was 33 ± 23. Retention and questionnaire completion rates were both 93 % (n = 14). Survivors logged into the virtual environment a total of 122 times, logged an average of 49 min/log-in, and 12 (80 %) attended support groups and social activities. Median usability score indicated lower than average usability. Improvement trends in social support, loneliness, and depressive symptoms were found, but significant changes in mean questionnaire scores were not found.

CONCLUSIONS

Overall, the results suggest that using a virtual environment to foster social support exchanges, social network interactions, and recovery education after stroke is feasible. Similar to other chronic disease populations, stroke survivor adoption of a virtual environment likely requires ongoing technical assistance, repetition of instructions, and opportunities for practice to reinforce engagement.

TRIAL REGISTRATION

NCT05487144.

Stroke awareness among community health workers from rural health blocks of Thiruvananthapuram, India

Objectives

Secondary prevention of stroke largely depends on risk factor control and lifestyle modification. Optimal secondary prevention strategies are limited in rural settings due to the shortage of primary care physicians and neurologists. Awareness of community health workers (CHWs) regarding stroke and its management remains largely unexplored. The current cross-sectional study aimed at assessing the knowledge, attitude, and practice (KAP) of CHWs regarding stroke care.

Materials and Methods

A structured KAP questionnaire was administered among 510 CHWs from randomly selected rural health blocks of Thiruvananthapuram, Kerala, India.

Results

Knowledge assessment showed that the CHWs possessed an average knowledge of stroke care. The mean attitude and practice scores were higher, indicating a favorable attitude and good practice. The overall mean (standard deviation) KAP scores of CHWs were 13.54 (4.43) against a total score of 23. The KAP scores were highest among palliative care nurses. The stroke awareness of the accredited social health activists was comparatively lower than other CHWs. Factors such as age and years of work experience were not correlated to the KAP scores.

Conclusion

Recurrent strokes remain a major challenge in primary care. Overall, the health workers demonstrated average knowledge, favorable attitudes, and positive practices. The study highlights the importance of training accredited social health activists (ASHAs) and other CHWs in stroke to improve secondary prevention strategies.

Efficacy, feasibility, and acceptability of in-home stroke education for stroke survivors

Barriers to learning after a stroke may prevent stroke survivors from acquiring helpful information regarding stroke prevention and preparedness. The objective of this study was to evaluate the efficacy, feasibility, and acceptability of a novel in-home stroke education program for survivors in the acute phase following a stroke. Study participants completed four in-home education sessions about stroke prevention and preparedness following their discharge home from inpatient rehabilitation. Sessions were designed to be completed within an 8-week period. Sessions were presented with evidence-based teaching methods and could be tailored to individual needs. Participants completed short quizzes before and after each education session to measure knowledge attainment. Forty-nine participants were included in this study. On average, the program was completed in 10 weeks, or 69.5 days (SD 29.6), and visits lasted 66.26 minutes; 81.5% of participants completed Visit 1, 77.5% completed Visit 2, and 73.5% completed Visits 3 and 4. Statistically significant changes from pretest-to-posttest scores were found for all races and genders and for ages 50-79. There was no significant change in pretest-to-posttest scores for participants over age 80 (n = 3). Results show that delivering a stroke education program can be accomplished, on an expanded timeline. The program was effective in increasing stroke knowledge for participants recently discharged from inpatient rehabilitation following a stroke.

Pharmacological, non-invasive brain stimulation and psychological interventions, and their combination, for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery, yet is often undetected or inadequately treated.

OBJECTIVES

To evaluate the benefits and harms of pharmacological intervention, non-invasive brain stimulation, psychological therapy, or combinations of these to treat depression after stroke.

SEARCH METHODS

This is a living systematic review. We search for new evidence every two months and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. We searched the Specialised Registers of Cochrane Stroke, and Cochrane Depression Anxiety and Neurosis, CENTRAL, MEDLINE, Embase, five other databases, two clinical trials registers, reference lists and conference proceedings (February 2022). We contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) non-invasive brain stimulation with sham stimulation or usual care; 3) psychological therapy with usual care or attention control; 4) pharmacological intervention and psychological therapy with pharmacological intervention and usual care or attention control; 5) pharmacological intervention and non-invasive brain stimulation with pharmacological intervention and sham stimulation or usual care; 6) non-invasive brain stimulation and psychological therapy versus sham brain stimulation or usual care and psychological therapy; 7) pharmacological intervention and psychological therapy with placebo and psychological therapy; 8) pharmacological intervention and non-invasive brain stimulation with placebo and non-invasive brain stimulation; and 9) non-invasive brain stimulation and psychological therapy versus non-invasive brain stimulation and usual care or attention control, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 65 trials (72 comparisons) with 5831 participants. Data were available for: 1) 20 comparisons; 2) nine comparisons; 3) 25 comparisons; 4) three comparisons; 5) 14 comparisons; and 6) one comparison. We found no trials for comparisons 7 to 9. Comparison 1: Pharmacological interventions Very low-certainty evidence from eight trials suggests pharmacological interventions decreased the number of people meeting the study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; P = 0.002; 8 RCTs; 1025 participants) at end of treatment and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with inadequate response to treatment (RR 0.47, 95% CI 0.32 to 0.70; P = 0.0002; 6 RCTs; 511 participants) compared to placebo. More adverse events related to the central nervous system (CNS) (RR 1.55, 95% CI 1.12 to 2.15; P = 0.008; 5 RCTs; 488 participants; very low-certainty evidence) and gastrointestinal system (RR 1.62, 95% CI 1.19 to 2.19; P = 0.002; 4 RCTs; 473 participants; very low-certainty evidence) were noted in the pharmacological intervention than in the placebo group. Comparison 2: Non-invasive brain stimulation Very low-certainty evidence from two trials show that non-invasive brain stimulation had little to no effect on the number of people meeting the study criteria for depression (RR 0.67, 95% CI 0.39 to 1.14; P = 0.14; 2 RCTs; 130 participants) and the number of people with inadequate response to treatment (RR 0.84, 95% CI 0.52, 1.37; P = 0.49; 2 RCTs; 130 participants) compared to sham stimulation. Non-invasive brain stimulation resulted in no deaths. Comparison 3: Psychological therapy Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; P = 0.01; 521 participants) compared to usual care/attention control. No trials of psychological therapy reported on the outcome inadequate response to treatment. No differences in the number of deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Comparison 4: Pharmacological interventions with psychological therapy No trials of this combination reported on the primary outcomes. Combination therapy resulted in no deaths. Comparison 5: Pharmacological interventions with non-invasive brain stimulation Non-invasive brain stimulation with pharmacological intervention reduced the number of people meeting study criteria for depression at end of treatment (RR 0.77, 95% CI 0.64 to 0.91; P = 0.002; 3 RCTs; 392 participants; low-certainty evidence) but not the number of people with inadequate response to treatment (RR 0.95, 95% CI 0.69 to 1.30; P = 0.75; 3 RCTs; 392 participants; very low-certainty evidence) compared to pharmacological therapy alone. Very low-certainty evidence from five trials suggest no difference in deaths between this combination therapy (RR 1.06, 95% CI 0.27 to 4.16; P = 0.93; 487 participants) compared to pharmacological therapy intervention and sham stimulation or usual care. Comparison 6: Non-invasive brain stimulation with psychological therapy No trials of this combination reported on the primary outcomes.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological, psychological and combination therapies can reduce the prevalence of depression while non-invasive brain stimulation had little to no effect on the prevalence of depression. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Cognitive assessment and rehabilitation tools for stroke and dementia: An online survey of Russian speaking clinicians

Our objective was to survey opinions on cognitive assessment and rehabilitation of Russian-speaking clinicians working with stroke and dementia patients. An online survey was circulated to professional communities soliciting feedback from clinicians about methods used for cognitive assessment and rehabilitation; expected cognitive impairments in dementia and stroke; variables affecting the cognitive abilities of patients; and topics presented during psycho-educational initiatives. Forty-eight physicians, 50 psychologists, and 12 speech-language pathologists completed the survey. 96% of participants reported estimating the cognitive abilities of patients while performing diagnostics and treatment in clinical settings. The most popular tools for cognitive assessment were Russian versions of the MoCA, MMSE, Luria Neuropsychological Battery, and Frontal Assessment Battery (FAB). 60% of participants reported the provision of cognitive rehabilitation, and 61% provided psychoeducation. All groups reported that the cognitive reserve and the idiopathic features of a brain lesion were the main factors influencing patients' cognitive profile. In the case of stroke patients, clinicians observed aphasia, as well as impairments in attention, memory, and reasoning. For patients with dementia, memory deficits were coincident with executive/frontal, praxis, and visuo-perceptual impairments. Psychotherapy-related psychoeducation was delivered by most of the clinicians. The captured patterns of clinical practice followed, in part, Russian national guidelines for cognitive rehabilitation and, in part, international protocols, wherein we found some professional group differences in implementation of practice. The profile in approaches to stroke and dementia assessment and rehabilitation reveal a new benchmark for future studies and for the development of policies for neuropsychological assessment and treatment in Russian language.

Acupuncture and massage combined with rehabilitation therapy for hemiplegia after stroke: A protocol for systematic review and meta-analysis

BACKGROUND

The purpose of this study was to evaluate the effectiveness and safety of acupuncture and massage combined with rehabilitation in the treatment of hemiplegia after stroke.

METHODS

To collect relevant literature, we will research following databases: Medicine, PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan-Fang Database, Chongqing VIP Chinese Science and Technology Periodicaols Database, and China Biomedical Database; the time is from its creation to May 2021, and the language is limited to Chinese and English. In addition, we will retrieve other literature resources, including the Chinese Clinical Trial Register and conference articles. Two reviewers will independently complete the literature screen and data extraction and quality assessment of the included studies will be independently completed by two other researchers. The primary outcomes included the Modified Ashworth scale and the simplified Fugl-Meyer Assessment scale. The Modified Barthel Index, the China Stroke Scale, and adverse reactions as secondary outcomes were assessed. RevMan V.5.4.1 software will be used for meta-analysis, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) will be used to assess the quality of evidence.

RESULTS

This systematic review will provide a high-quality synthesis to evaluate the efficacy and safety of acupuncture and massage combined with rehabilitation in the treatment of hemiplegia after stroke, providing a reference for the safe and effective treatment of hemiplegia after stroke.

CONCLUSION

This study provides evidence that acupuncture and massage combined with rehabilitation therapy is effective.

ETHICS AND DISSEMINATION

The protocol of the systematic review does not require ethical approval because it does not involve humans. This article will be published in peer-reviewed journals and presented at relevant conferences.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202210026.

Caring for Our Caregivers: a feasibility study of caregiver preparedness training within inpatient brain injury rehabilitation

Background/aims

Evidence-based inpatient caregiver training may ensure that caregiver needs are met and hospital readmission costs reduced. The aim of this study was to evaluate the feasibility of implementing a caregiver education model, Caring for Our Caregivers, within an inpatient brain injury programme.

Methods

A total of 32 adults were admitted to inpatient neurorehabilitation during the 7-week feasibility trial. The three-step Caring for Our Caregivers programme included evidence-based recommendations following a caregiver needs assessment, goal setting and hands-on training. Satisfaction levels and caregiver preparedness were assessed via a survey.

Results

The caregiver needs assessment and goal collaboration was completed within 5 days 66% of the time. Results indicated an even distribution of hands-on (47%) and discussion-based (53%) education. Caregivers and staff identified high levels of satisfaction with the programme.

Conclusions

Early engagement, collaborative goals and hands-on training of the family caregiver of a client with acquired brain injury during inpatient rehabilitation demonstrated initial feasibility with positive implications for caregiver satisfaction and community discharge.

Non-Immersive Virtual Reality for Post-Stroke Upper Extremity Rehabilitation: A Small Cohort Randomized Trial

Immersive and non-immersive virtual reality (NIVR) technology can supplement and improve standard physiotherapy and neurorehabilitation in post-stroke patients. We aimed to use MIRA software to investigate the efficiency of specific NIVR therapy as a standalone intervention, versus standardized physiotherapy for upper extremity rehabilitation in patients post-stroke. Fifty-five inpatients were randomized to control groups (applying standard physiotherapy and dexterity exercises) and experimental groups (applying NIVR and dexterity exercises). The two groups were subdivided into subacute (six months to four years post-stroke survival patients). The following standardized tests were applied at baseline and after two weeks post-therapy: Fugl-Meyer Assessment for Upper Extremity (FMUE), the Modified Rankin Scale (MRS), Functional Independence Measure (FIM), Active Range of Motion (AROM), Manual Muscle Testing (MMT), Modified Ashworth Scale (MAS), and Functional Reach Test (FRT). The Kruskal-Wallis test was used to determine if there were significant differences between the groups, followed with pairwise comparisons. The Wilcoxon Signed-Rank test was used to determine the significance of pre to post-therapy changes. The Wilcoxon Signed-Rank test showed significant differences in all four groups regarding MMT, FMUE, and FIM assessments pre- and post-therapy, while for AROM, only experimental groups registered significant differences. Independent Kruskal-Wallis results showed that the subacute experimental group outcomes were statistically significant regarding the assessments, especially in comparison with the control groups. The results suggest that NIVR rehabilitation is efficient to be administered to post-stroke patients, and the study design can be used for a further trial, in the perspective that NIVR therapy can be more efficient than standard physiotherapy within the first six months post-stroke.

Comparative Effectiveness of Different Combinations of Treatment Interventions in Patients with Stroke at the Convalescence Stage Based on the Markov Decision Process

Objective

The objective of this study was to compare the effectiveness of different combinations of interventions in patients with stroke at the convalescence stage based on the electronic health records (EHRs) by using the Markov decision process (MDP) theory and explore the feasibility of the Markov model in the real-world study (RWS).

Methods

Screening was conducted for patients with stroke at the convalescence stage who were admitted to the Third Affiliated Hospital of Zhejiang Chinese Medical University from January 2012 to January 2017 based on the EHRs. The relevant clinical data were extracted, and the appropriate conversion was made (state-action-reward) according to the Markov model. The transformed data were analysed and solved by the MDP to obtain the best interventions for patients with various stroke recovery periods.

Results

926 patients with stroke at the convalescence stage were initially selected. And according to the inclusion exclusion criteria, 854 patients were screened. Through the MDP, we obtained the following results: (1)when the patients with stroke at the convalescence stage have a medical history, but no complications, and mild neurological impairment, ≥66-year- and 18–45-year-old patients are advised to choose acupuncture treatment. 46–65-year-old patients are advised to choose rehabilitation treatment. When patients with moderate to severe neurological impairment, patients are advised to choose rehabilitation, Chinese herbal decoction, and acupuncture combined therapy. (2) Without complications or medical history, patients who are ≥ 66 years old are recommended to choose rehabilitation treatment when the nerve function impairment is mild; rehabilitation and acupuncture treatment are recommended when moderate and severe injuries are caused. (3) The combination of rehabilitation, Chinese herbal decoction, and acupuncture treatment is recommended for patients with phlegm and blood stasis. Acupuncture treatment is recommended for patients with mild impairment of nerve function in qi deficiency and blood stasis type. Rehabilitation, Chinese herbal decoction, and acupuncture treatment are recommended for moderate-severe injuries.

Conclusions

The MDP makes it possible to study the effectiveness of various treatment methods in stroke patients who are at the convalescence stage. Further exploratory studies using MDP theory in other areas in which complex interventions are common would be worthwhile.

Pharmacological, psychological and non-invasive brain stimulation interventions for preventing depression after stroke

BACKGROUND

Depression is an important consequence of stroke that influences recovery yet often is not detected, or is inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and previously updated in 2008.

OBJECTIVES

The primary objective is to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation, or combinations of these interventions reduce the incidence of diagnosable depression after stroke. Secondary objectives are to test the hypothesis that pharmacological, psychological therapy, non-invasive brain stimulation or combinations of these interventions reduce levels of depressive symptoms and dependency, and improve physical functioning after stroke. We also aim to determine the safety of, and adherence to, the interventions.

SEARCH METHODS

We searched the Specialised Register of Cochrane Stroke and the Cochrane Depression Anxiety and Neurosis (last searched August 2018). In addition, we searched the following databases; Cochrane Central Register of Controlled Trials, CENTRAL (the Cochrane Library, 2018, Issue 8), MEDLINE (1966 to August 2018), Embase (1980 to August 2018), PsycINFO (1967 to August 2018), CINAHL (1982 to August 2018) and three Web of Science indexes (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP); to August 2018 and ClinicalTrials.gov; to August 2018), conference proceedings; we also contacted study authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing: 1) pharmacological interventions with placebo; 2) one of various forms of psychological therapy with usual care and/or attention control; 3) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; 4) a pharmacological intervention and one of various forms of psychological therapy with a pharmacological intervention and usual care and/or attention control; 5) non-invasive brain stimulation and pharmacological intervention with a pharmacological intervention and sham stimulation or usual care; 6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; 7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; 8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and 9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of preventing depression after stroke.

DATA COLLECTION AND ANALYSIS

Review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) for dichotomous data with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 19 RCTs (21 interventions), with 1771 participants in the review. Data were available for 12 pharmacological trials (14 interventions) and seven psychological trials. There were no trials of non-invasive brain stimulation compared with sham stimulation or usual care, a combination of pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy, or a combination of non-invasive brain stimulation and a pharmacological intervention with a pharmacological intervention and sham stimulation or usual care to prevent depression after stroke. Treatment effects were observed on the primary outcome of meeting the study criteria for depression at the end of treatment: there is very low-certainty evidence from eight trials (nine interventions) that pharmacological interventions decrease the number of people meeting the study criteria for depression (RR 0.50, 95% CI 0.37 to 0.68; 734 participants) compared to placebo. There is very low-certainty evidence from two trials that psychological interventions reduce the proportion of people meeting the study criteria for depression (RR 0.68, 95% CI 0.49 to 0.94, 607 participants) compared to usual care and/or attention control. Eight trials (nine interventions) found no difference in death and other adverse events between pharmacological intervention and placebo groups (RR 1.25, 95% CI 0.32 to 4.91; 496 participants) based on very low-certainty evidence. Five trials found no difference in psychological intervention and usual care and/or attention control groups for death and other adverse events (RR 1.18, 95% CI 0.73 to 1.91; 975 participants) based on very low-certainty evidence.

AUTHORS' CONCLUSIONS

The available evidence suggests that pharmacological interventions and psychological therapy may prevent depression and improve mood after stroke. However, there is very low certainty in these conclusions because of the very low-certainty evidence. More trials are required before reliable recommendations can be made about the routine use of such treatments after stroke.

Pharmacological, psychological, and non-invasive brain stimulation interventions for treating depression after stroke

BACKGROUND

Depression is an important morbidity associated with stroke that impacts on recovery yet often undetected or inadequately treated. This is an update and expansion of a Cochrane Review first published in 2004 and updated in 2008.

OBJECTIVES

Primary objective • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce the prevalence of diagnosable depression after stroke Secondary objectives • To determine whether pharmacological therapy, non-invasive brain stimulation, psychological therapy, or combinations of these interventions reduce levels of depressive symptoms, improve physical and neurological function and health-related quality of life, and reduce dependency after stroke • To assess the safety of and adherence to such treatments SEARCH METHODS: We searched the Specialised Registers of Cochrane Stroke and Cochrane Depression Anxiety and Neurosis (last searched August 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), in the Cochrane Library, MEDLINE (1966 to August 2018), Embase (1980 to August 2018), the Cumulative Index to Nursing and Alllied Health Literature (CINAHL) (1982 to August 2018), PsycINFO (1967 to August 2018), and Web of Science (2002 to August 2018). We also searched reference lists, clinical trial registers (World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) to August 2018; ClinicalTrials.gov to August 2018), and conference proceedings, and we contacted study authors.

SELECTION CRITERIA

Randomised controlled trials comparing (1) pharmacological interventions with placebo; (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care; (3) one of various forms of psychological therapy with usual care and/or attention control; (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control; (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care; (6) pharmacological intervention and one of various forms of psychological therapy with placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation with placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy, with the intention of treating depression after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed risk of bias, and extracted data from all included studies. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data, and risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I² statistic and certainty of the evidence according to GRADE.

MAIN RESULTS

We included 49 trials (56 comparisons) with 3342 participants. Data were available for: (1) pharmacological interventions with placebo (with 20 pharmacological comparisons); (2) one of various forms of non-invasive brain stimulation with sham stimulation or usual care (with eight non-invasive brain stimulation comparisons); (3) one of various forms of psychological therapy with usual care and/or attention control (with 16 psychological therapy comparisons); (4) pharmacological intervention and various forms of psychological therapy with pharmacological intervention and usual care and/or attention control (with two comparisons); and (5) non-invasive brain stimulation and pharmacological intervention with pharmacological intervention and sham stimulation or usual care (with 10 comparisons). We found no trials for the following comparisons: (6) pharmacological intervention and various forms of psychological therapy interventions versus placebo and psychological therapy; (7) pharmacological intervention and non-invasive brain stimulation versus placebo plus non-invasive brain stimulation; (8) non-invasive brain stimulation and one of various forms of psychological therapy versus non-invasive brain stimulation plus usual care and/or attention control; and (9) non-invasive brain stimulation and one of various forms of psychological therapy versus sham brain stimulation or usual care plus psychological therapy. Treatment effects observed: very low-certainty evidence from eight trials suggests that pharmacological interventions decreased the number of people meeting study criteria for depression (RR 0.70, 95% CI 0.55 to 0.88; 1025 participants) at end of treatment, and very low-certainty evidence from six trials suggests that pharmacological interventions decreased the number of people with less than 50% reduction in depression scale scores at end of treatment (RR 0.47, 95% CI 0.32 to 0.69; 511 participants) compared to placebo. No trials of non-invasive brain stimulation reported on meeting study criteria for depression at end of treatment. Only one trial of non-invasive brain stimulation reported on the outcome <50% reduction in depression scale scores; thus, we were unable to perform a meta-analysis for this outcome. Very low-certainty evidence from six trials suggests that psychological therapy decreased the number of people meeting the study criteria for depression at end of treatment (RR 0.77, 95% CI 0.62 to 0.95; 521 participants) compared to usual care/attention control. No trials of combination therapies reported on the number of people meeting the study criteria for depression at end of treatment. Only one trial of combination (non-invasive brain stimulation and pharmacological intervention) therapy reported <50% reduction in depression scale scores at end of treatment. Thus, we were unable to perform a meta-analysis for this outcome. Five trials reported adverse events related to the central nervous system (CNS) and noted significant harm in the pharmacological interventions group (RR 1.55, 95% CI 1.12 to 2.15; 488 participants; very low-certainty evidence). Four trials found significant gastrointestinal adverse events in the pharmacological interventions group (RR 1.62, 95% CI 1.19 to 2.19; 473 participants; very low-certainty evidence) compared to the placebo group. No significant deaths or adverse events were found in the psychological therapy group compared to the usual care/attention control group. Non-invasive brain stimulation interventions and combination therapies resulted in no deaths.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggests that pharmacological or psychological therapies can reduce the prevalence of depression. This very low-certainty evidence suggests that pharmacological therapy, psychological therapy, non-invasive brain stimulation, and combined interventions can reduce depressive symptoms. Pharmacological intervention was associated with adverse events related to the CNS and the gastrointestinal tract. More research is required before recommendations can be made about the routine use of such treatments.

Virtual Reality Games as an Adjunct in Improving Upper Limb Function and General Health among Stroke Survivors

Virtual reality (VR) games has the potential to improve patient outcomes in stroke rehabilitation. However, there is limited information on VR games as an adjunct to standard physiotherapy in improving upper limb function. This study involved 36 participants in both experimental (n = 18) and control (n = 18) groups with a mean age (SD) of 57 (8.20) and 63 (10.54) years, respectively. Outcome measures were the Fugl-Meyer assessment for upper extremities (FMA-UE), Wolf motor function test (WMFT), intrinsic motivation inventory (IMI), Lawton of instrumental activities of daily living (IADL), and stroke impact scale (SIS) assessed at pre-post intervention. The experimental group had 0.5 h of upper limb (UL) VR games with 1.5 h of standard physiotherapy, and the control group received 2 h of standard physiotherapy. The intervention for both groups was performed once a week for eight consecutive weeks. The results showed a significant time-group interaction effect for IMI (p = 0.001), Lawton IADL (p = 0.01) and SIS domain of communication (p = 0.03). A significant time effect was found in FMA-UE (p = 0.001), WMFT (p = 0.001), Lawton IADL (p = 0.01), and SIS domains; strength, ADL and stroke recovery (p < 0.05). These results indicated an improvement in UL motor ability, sensory function, instrumental ADL, and quality of life in both groups after eight weeks of intervention. However, no significant (p > 0.05) group effect on all the outcome measures was demonstrated. Thus, replacing a portion of standard physiotherapy time with VR games was equally effective in improving UL function and general health compared to receiving only standard physiotherapy among stroke survivors.

A newly designed intensive caregiver education program reduces cognitive impairment, anxiety, and depression in patients with acute ischemic stroke

This study aimed to evaluate the effect of a newly designed intensive caregiver education program (ICEP) on reducing cognitive impairment, anxiety, and depression in acute ischemic stroke (AIS) patients. One hundred and ninety-six AIS patients were divided into ICEP group and Control group in a 1:1 ratio using blocked randomization method. In the ICEP group, the caregivers received ICEP, while in the Control group caregivers received usual education and guidance. All patients received conventional rehabilitation treatment. Cognitive impairment (assessed by Mini Mental State Examination (MMSE) score and Montreal Cognitive Assessment (MoCA) score), anxiety (assessed by Hospital Anxiety and Depression Scale (HADS)-A score and Self-rating Anxiety Scale (SAS) score), and depression (assessed by HADS-D score and Self-rating Depression Scale (SDS) score) were assessed at baseline (M0), 3 months (M3), 6 months (M6), and 12 months (M12). Cognitive impairment score at M12 and cognitive impairment score change (M12-M0) were increased, while cognitive impairment rate at M12 was reduced in the ICEP group compared with the Control group. Anxiety score change (M12-M0), anxiety score at M12, and anxiety rate at M12 were decreased in the ICEP group compared with the Control group. Depression score change (M12-M0), depression score at M12, and depression rate at M12 were lower in the ICEP group compared with the Control group. Further subgroup analysis based on baseline features also provided similar results. In conclusion, ICEP effectively reduced cognitive impairment, anxiety, and depression in AIS patients.

Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

BACKGROUND

Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population.

OBJECTIVES

The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects.

DESIGN

A single arm, pre/post, pragmatic feasibility study of 20-40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost.

CONCLUSIONS

Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.

Elderly Stroke Rehabilitation: Overcoming the Complications and Its Associated Challenges

There have been many advances in management of cerebrovascular diseases. However, stroke is still one of the leading causes of disabilities and mortality worldwide with significant socioeconomic burden. This review summarizes the consequences of stroke in the elderly, predictors of stroke rehabilitation outcomes, role of rehabilitation in neuronal recovery, importance of stroke rehabilitation units, and types of rehabilitation resources and services available in Singapore. We also present the challenges faced by the elderly stroke survivors in the local setting and propose strategies to overcome the barriers to rehabilitation in this aging population.

Depressive Symptoms in Individuals after Stroke in a Home-Based Rehabilitation Setting

Poststroke depression has been shown to affect rehabilitation progress. This study evaluated patients after stroke who actively participated in a home-based rehabilitation program to determine variables that correlated with depressive symptoms in this population. A retrospective review of patients who were provided rehabilitation by Community Stroke Rehabilitation Team clinicians between January 1, 2009, and September 30, 2015, was completed. Logistic regression analysis was conducted to determine which demographic and outcome variables (Functional Independence Measure [FIM™] and Reintegration to Normal Living Index [RNLI]) were independently associated with depressive symptoms, as defined by Patient Health Questionnaire (PHQ-9) scores. 889 patients (53.2% male, mean age = 69.8 years) were included. Based on PHQ-9 scores, 89.7% of patients presented with no or mild depressive symptoms (PHQ-9 < 10) and 10.3% were considered to have moderate to severe depressive symptoms (PHQ-9 ≥ 10). The regression demonstrated that referral from outpatient, community care access centre, or community settings (OR = 1.89, p = 0.04), low RNLI scores (OR = 0.92; p = 0.001), and younger age (OR = 0.96; p < 0.001) predicted patients having moderate to severe depressive symptoms. Given the impact of poststroke depression on rehabilitation, clinicians should consider the potential impact of referral source, community reintegration, and age when monitoring and treating depressive symptoms.

Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient's caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial

BACKGROUND

Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment, but necessary to prevent recurrence and improve patients' quality of life. To involve a referent nurse and a caregiver from the patient's social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family. The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up, and an interventional program directed to the patient and a caregiving member of their social circle, as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke.

METHODS/DESIGN

The design is a randomized, controlled, clinical trial conducted in the French Stroke Unit of the Strokavenir network. In total, 410 patients will be recruited and randomized in optimized follow up or usual follow up for 2 years. In both group, patients will be seen by a neurologist at 6, 12 and 24 months. The optimized follow up will include follow up by a nurse from the vascular neurology department, including therapeutic follow up, and a training program on secondary prevention directed to the patient and a caregiving member of their social circle. After discharge, a monthly telephone interview, in the first year and every 3 months in the second year, will be performed by the nurse. At 6, 12 and 24 month, the nurse will give the patient and caregiver another training session. Usual follow up is only done by the patient's general practitioner, after classical information on secondary prevention of risk factors during hospitalization. The primary outcome measure is blood pressure measured after the first year of follow up. Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been randomized. Secondary endpoints are associated mortality, morbidity, recurrence, drug side-effects and medico-economic analysis.

DISCUSSION

The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke, personalizing the role of the nurse and including the patient's caregiver.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT 02132364. Registered on 7 May 2014. EUDRACT, A 00473-40.

Content validity and satisfaction with a caregiver-integrated web-based rehabilitation intervention for persons with stroke

Background Family members provide valuable contributions during rehabilitation after stroke, but frequently report higher incidences of burden, depression, and social isolation during caregiving. Thus, effective interventions to reduce stroke impact on the family are needed. Objectives To evaluate the content validity and satisfaction of a caregiver-focused web-based intervention designed to improve stroke survivor physical function while reducing caregiver negative outcomes. Methods Caregivers of individuals with stroke (N = 6) and expert rehabilitation researchers (N = 4) were presented with a novel, web-based intervention (CARE-CITE) designed to foster problem-solving and skill-building while facilitating caregiver involvement during constraint-induced movement therapy. Caregivers rated CARE-CITE for usefulness, ease of use, acceptability, and time to complete. Rehabilitation experts evaluated content for accuracy, feasibility, acceptability, problem relevance and ease of use. Ratings were assessed using a five-point Likert-type response scales (1 = strongly disagree to 5 = strongly agree). Results On average, all caregivers agreed or strongly agreed that the modules were useful (4.42), easy to use (4.60), and acceptable (4.41). Mean total satisfaction score was 4.45, and average review time was 15 min per module. Expert reviewers agreed or strongly agreed that each module was accurate (4.95), feasible (4.8), easy to use (4.86), acceptable (4.96), and had appropriate problem relevance (4.65). Conclusions The CARE-CITE intervention may be a viable program for caregivers of patients with stroke. Currently a pilot study is underway to evaluate the impact of the intervention on caregiver mental health, family conflict around stroke recovery and stroke survivor upper extremity function.

Feasibility of a Novel Intervention to Improve Participation after Stroke

Introduction

Stroke is a leading cause of serious, long-term disability in the US. With shorter inpatient hospital stays, more time in rehabilitation is devoted to medical stabilization and less on skills to regain independence in daily activities. The transition home may be an opportunity for intervention focused on regaining independence. We propose an enhanced rehabilitation transition program called: Community Participation Transition after Stroke (COMPASS).

Method

A prospective, randomized, single-blinded, parallel-group pilot study was completed to demonstrate feasibility with N=15 participants.

Findings

Fidelity to the protocol was achieved: the COMPASS group received 81% of the planned minutes and 83% of the intervention visits. There was no difference between groups for healthcare utilization or falls. Adherence was 85% at 3-months and 71% at 9-months for the home modification intervention. At 6-months, the COMPASS group's reintegration to normal living scores improved by 17.39 points for the COMPASS group, and 1.30 for the control group. Environmental barriers decreased in both groups.

Conclusion

This pilot study demonstrated that it is feasible to implement a community participation intervention during the period of transitioning home from inpatient rehabilitation for stroke survivors. Additional studies are necessary to determine the efficacy of the intervention.

Trajectories of Stroke Care in Ontario: Which Path to Best Care?

BACKGROUND

Few studies have tracked stroke survivors through transitions across the health system and identified the most common trajectories and quality of care received. The objectives of our study were to examine the trajectories that incident stroke patients experience and to quantify the extent to which their care adhered to the best practices for stroke care.

METHODS

A population-based cohort of first-ever stroke/transient ischemic attack (TIA) patients from the 2012/13 Ontario Stroke Audit was linked to administrative databases using an encrypted health card number to identify dominant trajectories (N=12,362). All trajectories began in the emergency department (ED) and were defined by the transitions that followed immediately after the ED. Quality indicators were calculated to quantify best practice adherence within trajectories.

RESULTS

Six trajectories of stroke care were identified with significant variability in patient characteristics and quality of care received. Almost two-thirds (64.5%) required hospital admission. Trajectories that only involved the ED had the lowest rates of brain and carotid artery imaging (91.5 and 44.2%, respectively). Less than 20% of patients in trajectories involving hospital admissions received care on a stroke unit. The trajectory involving inpatient rehabilitation received suboptimal secondary prevention measures.

CONCLUSIONS

There are six main trajectories stroke patients follow, and adherence to best practices varies by trajectory. Trajectories resulting in patients being transitioned to home care following ED management only are least likely and those including inpatient rehabilitation are most likely to receive stroke best practices. Increased time in facility-based care results in greater access to best practices. Stroke patients receiving only ED care require closer follow-up by stroke specialists.

Do cognitive, language, or physical impairments affect participation in a trial of self-management programs for stroke?

BACKGROUND

Research studies may have limited generalizability when survivors of stroke with physical, language, or cognitive impairments are excluded.

AIMS

To assess whether presence of cognitive, language, or global impairments affects participation in self-management programs.

METHODS

Stroke survivors were recruited in South Australia from seven hospitals or via advertisements into a randomized controlled trial (1:1:1 ratio) of a Stroke Self-Management Program, the Stanford chronic condition self-management program, or standard care. Impairment status was measured using: Cognistat (cognition), Frenchay Aphasia assessment (language), modified Rankin Score (mRS; where score 3-5 = global disability).

PRIMARY OUTCOMES

participation (i.e. booked, accessed, and completed a program (defined as attending ≥ 50% of sessions)) and safety (i.e. adverse events). Outcomes were compared by impairment status.

RESULTS

Among 315 people screened 143/149 eligible were randomized (median age 71 years; 41% male; with impairments: 62% cognitive, 34% language, 64% global disability). Participation did not differ by cognitive or language impairment status (cognitive 75%, no cognitive 68%, p = 0.54; language 78%, no language 69%, p = 0.42). However, participation did vary by global impairment status (global disability 61%, no disability 96%, p < 0.001). Participants with cognitive impairment experienced more adverse events (severe n = 9 versus no cognitive impairment n = 1).

CONCLUSION

Survivors of stroke with cognitive, language, or global impairments are able to participate in self-management programs and should be included in these types of research studies or programs. Reduced participation by those with global disability and the possibility of more adverse events in people with cognitive impairments needs to be considered.

Moving Toward an Understanding of Disability in Older U.S. Stroke Survivors

OBJECTIVES

We test a comprehensive model of disability in older stroke survivors and determine the relative contribution of neighborhood, economic, psychological, and medical factors to disability.

METHOD

The sample consisted of 728 stroke survivors from the National Health and Aging Trends Study (NHATS), who were 65 years and older living in community settings or residential care. Confirmatory factor analysis and structural equation modeling were used to test relationships between neighborhood, socioeconomic, psychological, and medical factors, and disability.

RESULTS

Economic and medical context were associated with disability directly and indirectly through physical impairment. Neighborhood context was associated with disability, but was only marginally statistically significant ( p = .05). The effect of economic and neighborhood factors was small compared with that of medical factors.

DISCUSSION

Neighborhood and economic factors account for a portion of the variance in disability among older stroke survivors beyond that of medical factors.

Disparities in home health service providers among Medicare beneficiaries with stroke

This study examined the intensity of home health services, as defined by the number of visits and service delivery by rehabilitation specialists, among Medicare beneficiaries with stroke. A cross-sectional secondary data analysis was conducted using 2009 home health claims data obtained from the Centers for Medicare and Medicaid Services' Research Data Assistance Center. There were no significant rural-urban differences in the number of home health visits. Rural beneficiaries were significantly less likely than urban beneficiaries to receive services from rehabilitation specialists. Current home health payment reform recommendations may have unintended consequences for rural home health beneficiaries who need therapy services.

Research and Design of a New Horizontal Lower Limb Rehabilitation Training Robot

This project focuses on the design of one robot to help long-time bedridden patients complete their daily leg rehabilitation training while lying in bed. Based on an analysis of many rehabilitation training modes and integrated with a traditional Chinese medicine (TCM) massage technique, a new horizontal lower limb rehabilitation training robot with four degrees of freedom is presented in this paper. The mechanical structural design, kinematic calculation and control system are introduced in detail. A robot prototype is fabricated and rehabilitation training experiments are carried out. The experimental results show that the robot can satisfy the requirements of a variety of rehabilitation training modes and has a certain degree of rehabilitation effectiveness.

Investigating the effects of a family-centered care program on stroke patients' adherence to their therapeutic regimens

Abstract Background: Stroke survivors have residual neurological impairment, which requires long-term support and care. In this situation family involvement in care process is necessary. However, as the family caregivers of stroke survivors are not necessarily supported by the health-care professionals, and they often feel inadequately prepared to deal with the physical, cognitive and emotional needs of the stroke survivors. Aim: The aim of this study was to investigate the effects of a family-centered care program on stroke patients' adherence to their therapeutic regimens. Methods: This is a posttest-only randomized controlled trial study, conducted on stroke patients and their family care-givers. The control group (n = 30) received only routine hospital services and the experimental group (n = 30) received routine hospital services plus a family-centered care program consisting of four steps; need assessment, educating families based on patients' needs, follow-ups by short phone interviews, and referral service. The data were collected via a demographic data form and "Adherence to the therapeutic regimens" Questionnaire between July 2011 to March 2012 and lasted two months for each subject. Data were assessed and analyzed with SPSS version 18. Findings: Study findings showed that the levels of adherence to the different components of the therapeutic regimens, including rehabilitations, medications and dietary regimen are significantly higher in the experimental group compared to the control group (P value< 0.001). Conclusion: By empowering patients' families and improving their adherence to the therapeutic regimens, family-centered care programs will be able to play an important role in management of physical and mental health of stroke patients.

Compliance With the Stroke Education Performance Measure in the Michigan Paul Coverdell National Acute Stroke Registry

Background and Purpose—

Stroke education, 1 of 8 endorsed stroke performance measures, consists of 5 specific subcomponents: risk factors, stroke warning signs, emergency medical service activation, physician follow-up, and discharge medications. We identified predictors of stroke education performance measure compliance in the Michigan Paul Coverdell National Acute Stroke Registry.

Methods—

Data were collected on 9609 acute stroke admissions to 20 registry hospitals during 2008 and 2009. Predictors of measure compliance (delivery of all 5 subcomponents) were determined using multivariable logistic regression.

Results—

Overall compliance with the stroke education measure was 61.8% (hospital-level compliance ranged between 16% and 93%). Compliance with individual subcomponents were risk factors (65.5%), stroke warning signs (68.9%), emergency medical service activation (66.8%), physician follow-up (92.9%), and discharge medications (91.5%). Age, gender, stroke subtype, prestroke ambulation, discharge destination, and hospital size were all significant independent predictors of compliance. Stroke education was delivered less often to patients who were ≥70 years of age, nonambulatory prestroke, not discharged to home, had transient ischemic attack, or hemorrhagic stroke.

Conclusions—

Only 60% of patients received stroke education consistent with the endorsed performance measures. Strategies to increase stroke education, including the impact of incorporating stroke-specific education measures into hospital care protocols, should be explored.

Home-based psychoeducational and mailed information programs for stroke-caregiving dyads post-discharge: a randomized trial

PURPOSE

This randomized trial compared 6- and 12-month outcomes of a home-based psychoeducational program to mailed information provided to 159 survivors of stroke (SS) and their spousal caregivers (CG).

METHODS

SS (age 50+) and CG were recruited as dyads post-discharge from inpatient rehabilitation. All dyads received mailed information for 12 months. Dyads randomized to the home-based group received an average of 36.7 h of psychoeducation over 6 months. Health status, depression, stress, burden, coping, support, mutuality and function were obtained on all dyads. Repeated measures analysis with linear mixed models was used to compare the groups for change over time in the outcome variables.

RESULTS

Both groups demonstrated less depression and stress over time. Compared to the mailed information group, SS in the home-based group demonstrated significantly improved self-reported health and cognitive function; CG demonstrated significantly improved self-reported health and coping strategies. Mutuality and social support decreased in both groups.

CONCLUSIONS

The home-based intervention was effective in improving self-reported health, coping skills in CG and cognitive functioning in SS. However, the finding that dyads in both groups demonstrated decreased depression and stress suggests that providing repeated doses of relevant, personalized information by mail may result in positive changes.

IMPLICATIONS FOR REHABILITATION

A stroke affects both the stroke survivor and the spousal caregiver, so nurses and therapists should use multicomponent strategies to provide education, support, counseling and linkages to community resources to ease the transition from hospital to home. Stroke may have a negative impact on the dyad's relationship with each other and also on the availability of support people in their lives during the 12 months after hospital discharge. Comprehensive stroke programs should encourage dyads to attend support groups and to seek individual and group counseling, as needed. Establishing an ongoing relationship with stroke survivors and their spouses and providing relevant and engaging information by mail can reduce stress and depression over 12 months post-discharge at a minimal cost. Nurses and therapists should consider home visits post-discharge to reinforce education and skills taught in the hospital, increase self-reported health in stroke survivors and spousal CG, increase coping skills and to link the couple to community resources.

Early sleep apnea screening on a stroke unit is feasible in patients with acute cerebral ischemia

Early screening for sleep apnea (SA) is rarely considered in patients with acute cerebral ischemia. We aimed to evaluate the feasibility of early SA screening on a stroke unit, its impact on post-discharge SA care and the relation of SA to clinical features. Patients with acute ischemic stroke (AIS) and transient ischemic attack (TIA) prospectively underwent overnight cardiorespiratory polygraphy within 3 ± 2 days of symptom-onset. Feasibility was defined as analyzable polygraphy in 90 % of studied patients. We enrolled 61 patients (84 % AIS, 16 % TIA): mean age 66 ± 8 years, 44 % men, median NIHSS 1 (0-15), median ESS 5 (0-13). Analyzability was given in 56/61 (91.8 %; one-sided 95 % CI, lower-bound 86.0 %) patients indicating excellent feasibility of early SA screening with no significant differences in stroke severity (100 % in TIA, 91 % minor stroke, 83 % major stroke, p = 0.474). Ninety-one percent (51/56) had an apnea-hypopnea index ≥ 5/h (median: 20/h [0-79]); 32 % (18/56) mild, 30 % (17/56) moderate, and 29 % (16/56) severe SA. When comparing sleep-related ischemic stroke (SIS) and non-SIS patients, no differences were found regarding the presence (95 vs. 89 %, p = 0.49) or severity (e.g., severe SA: 32 vs. 27 %, p = 0.69) of SA. After 12 months, 27/38 (71 %) patients given specific recommendations completed in-laboratory sleep work-up and 7/27 (25 %) were prescribed for non-invasive ventilatory correction. In conclusion, early SA screening is feasible in patients with acute cerebral ischemia and may have a positive impact on post-discharge SA care. Given the high frequency and atypical presentation of SA, early screening for SA should be considered in all acute cerebral ischemia patients.

Identifying Occupational Performance Barriers of Stroke Survivors: Utilization of a Home Assessment

BACKGROUND

Stroke survivors often have impairments that make it difficult for them to function safely in their home environment.

PURPOSE

The purpose of this study is to identify occupational performance barriers in the home and describe the subsequent recommendations offered to stroke survivors and their caregivers.

METHODS

An occupational therapist administered a home safety tool to assess stroke survivors' home environments, determine home safety problems, and provide recommendations.

FINDINGS

Among 76 stroke survivors, the greatest problems were indentified in the categories of bathroom, mobility, and communication. Two case studies illustrate the use of the home safety tool with this population.

IMPLICATIONS

The home safety tool is helpful in determining the safety needs of stroke survivors living at home. We recommend the use of the home safety tool for occupational therapists assessing the safety of the home environment.

Interprofessional stroke rehabilitation for stroke survivors using home care

OBJECTIVE

To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services.

METHODS

Randomized controlled trial of 101 community-living stroke survivors (<18 months post-stroke) using home care services. Subjects were randomized to intervention (n=52) or control (n=49) groups. The intervention was a 12-month specialized, evidence-based rehabilitation strategy involving an interprofessional team. The primary outcome was change in health-related quality of life and functioning (SF-36) from baseline to 12 months. Secondary outcomes were number of strokes during the 12-month follow-up, and changes in community reintegration (RNLI), perceived social support (PRQ85-Part 2), anxiety and depressive symptoms (Kessler-10), cognitive function (SPMSQ), and costs of use of health services from baseline to 12 months.

RESULTS

A total of 82 subjects completed the 12-month follow-up. Compared with the usual care group, stroke survivors in the intervention group showed clinically important (although not statistically significant) greater improvements from baseline in mean SF-36 physical functioning score (5.87, 95% CI -3.98 to 15.7; p=0.24) and social functioning score (9.03, CI-7.50 to 25.6; p=0.28). The groups did not differ for any of the secondary effectiveness outcomes. There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant (p=0.76).

CONCLUSIONS

A 12-month specialized, interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care. Clinicaltrials.gov identifier: NCT00463229.

The effect of motivational interviewing after ischemic stroke on patient knowledge and patient satisfaction with care: a pilot study

Knowledge of the warning signs of stroke may reduce the incidence of having a second stroke by receiving medical intervention in a timely manner. The need for stroke education is paramount to empower stroke patients to recognize the signs and symptoms of an impending stroke. The purpose of this pilot study was to develop and to evaluate the effectiveness of an educational method of providing stroke education in an acute care setting. Twenty patients were recruited and randomized to two groups. Group 1 received the standard of care: verbal and written education at the time of discharge by the discharge nurse. Group 2 received individualized protocol-driven verbal and written education with their caregiver present within the context of the Therapeutic Alliance Model using motivational interviewing techniques. Each group was sent a Stroke Knowledge Test and a patient satisfaction survey at 1 month. Results indicate that the enhanced education group received improved scores on the Stroke Knowledge Test and had better patient satisfaction scores regarding stroke education. An enhanced educational method using motivational interviewing and an individualized protocol-driven education intervention given to both the patient and a caregiver enhance stroke knowledge and patient satisfaction after discharge from the acute care setting.

Natural patterns of change in poststroke depressive symptoms and function

The objective of this study was to evaluate patterns of change in depressive symptoms and function in ischemic stroke patients 0 to 3 months poststroke. Twenty-three newly diagnosed ischemic stroke patients were enrolled in a study with nonrandomized prospective longitudinal design to assess function and depressive symptoms on admission, 2 weeks, 1 month, and 3 months poststroke in a tertiary care acute rehabilitation center in the Midwest. Participants' mean age was (69 ± 11.9), Mini Mental State Exam (MMSE ≥ 23), and NIH Stroke Scale (M = 2.8, SD = ± 2.3), and thus cognitively intact. Results suggest that the dominant pattern emerging for function (Functional Independence Measure) and depressive symptoms (Center for Epidemiologic Studies Depression Scale) showed significant improvement relative to baseline at 2 weeks poststroke and reached a plateau thereafter. The results may suggest that as stroke survivors gain independence in accomplishing activities of daily living, their moods improve as well.

Predictors of life satisfaction in stroke survivors and spousal caregivers after inpatient rehabilitation

A global measure of life satisfaction has become increasingly important as an adjunctive outcome of healthcare interventions for people with disabilities, including those caused by stroke. Life satisfaction of stroke survivors mayaffectcaregivingspouses, as well. The purpose of this study was to identify, among many physical and psychosocial variables, specific variables that were associated with life satisfaction at 12 months after discharge from inpatient rehabilitation, and variables that were predictive of life satisfaction 1 year later (at 24 months). Between 12 and 24 months, life satisfaction decreased for stroke survivors, while it increased for caregiving spouses. The relationship between the couple (mutuality) was the only variable that was a significant predictor of life satisfaction for both stroke survivors and their spouses.